July 5, 2012

[I]f a state doesn't expand its Medicaid program, most of those who would've been eligible for Medicaid will now become eligible for subsidies through ObamaCare's health-insurance exchanges. And those subsidies are paid in full by the feds.

Thus, New York, for example, would shift most of that $52 billion in new costs back to the federal government.

Of course, if states do shift those costs back to the feds, that will cause the federal cost of ObamaCare to skyrocket. If every state were to refuse to expand its Medicaid program, the feds would save roughly $130 billion in their share of Medicaid costs in 2014, but would have to pay $230 billion more in new exchange-based subsidies — for a net added cost of $100 billion. And that's just for the first year...

ObamaCare gives the feds the authority to step in, setting up and operating an exchange in any state that doesn't set up its own... [But f]ederal subsidies are available only through exchanges that the states set up. The feds can't offer subsidies through a federally run exchange.

Thus, if states neither expanded Medicaid nor set up exchanges, that would effectively block most of ObamaCare's new entitlement spending.

Given the potential for chaos in the Obamacare scheme if the states decline to participate, it's surprising that Justices Breyer and Kagan went along with the Chief Justice's opinion on the spending power. The original legislation had the states locked in, because they'd lose all their Medicaid funding if they didn't participate. That was held to be coercive, and thus not supportable by the spending power, which requires that states be given a choice whether to run federal programs and accept various related conditions. Under the Court's ruling, the states only lose the funding for the expansion of Medicaid, which makes it possible for them to say no, as many seem to be doing.

There's an elaborate set of moves in the future, and I wonder how far ahead the Chief Justice looked when he chose his position. Perhaps Obamacare is doomed by the seemingly modest, miminalist hit it took on the spending power issue. But wouldn't Breyer and Kagan have seen ahead too? Why did they join him? I'm not ready to give him genius points for skillful playing of the long game.

My word. Obamacare is like indigestion after a hot-dog eating contest. What started as something hard to swallow turned into a monstrous, horrifying expulsion of fecal matter. You think it's settled only to find that the worst hasn't even started. Plllthhhh.

I'm sure every single justice had a Bloomberg moment when combing over the text of the ACA. "Who wrote this shit?"

PPACA was a terrible, terrible piece of legislation. So terrible, even the wisest judges in the land could not comprehend all of its implications. I sincerely believe the people who wrote it don't even understand it. We won't know what is truly in it until we have lived it.

Its supposed to fail. Why do we concern ourselves with these issues? You need to comtemplate how a single payer system will operate. Its coming soon enough. America has spoken, they want it. Free healthcare for everyone. Yay!

PPACA was a terrible, terrible piece of legislation. So terrible, even the wisest judges in the land could not comprehend all of its implications.

This why we should never allow these huge omnibus types of legislation. Frankenstein bills. They start out with one purpose and get amended and added onto, larded up with pork and favors to the point that the original purpose is forgotten or so distorted.

Also why we shouldn't let people who know nothing about the industry or topic at hand craft bills that affect that industry. They have no idea what they are doing.....yet do it anyway.

Some interesting statistics from a survey by the United Nations International Health Organization:

Percentage of men and women who survived cancer five years after diagnosis:United States 65%England 46%Canada 42%

Percentage of patients diagnosed with diabetes who received treatment with six months:United States 93%England 15%Canada 43%

Percentage of seniors needing hip replacement who received it within six months:United States 90%England 15%Canada 43%Percentage referred to a medical specialist who see one within one month:U.S. 77%England 40%Canada 43%

Number of MRI scanners per million people:U.S. 71England 14Canada 18

Percentage of Seniors, with low income, who say they are in excellent health:U.S. 12%England 2%Canada 6%

I have seen these stats several times and they are correct and Allie- for an alleged nurse, you especially should be aware of these quality of service differences between the US and other countries. Oh I forgot you are one of those libs who holds their hands over their ears so they won't hear facts that conflict with their worldview.

Studies by the Commonwealth Fund found that 42% of Canadians waited 2 hours or more in the emergency room, vs. 29% in the U.S.; 57% waited 4 weeks or more to see a specialist, vs. 23% in the U.S., but Canadians had more chances of getting medical attentin at nights, or on weekends and holidays than their American neighbors without the need to visit an ER (54% compared to 61%).[66]

Statistics from the Canadian free market think tank Fraser Institute in 2008 indicate that the average wait time between the time when a general practitioner refers a patient for care and the receipt of treatment was almost four and a half months in 2008, roughly double what it had been 15 years before.[67]

A 2003 survey of hospital administrators conducted in Canada, the U.S., and three other countries found dissatisfaction with both the U.S. and Canadian systems. For example, 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman; 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery. "

I think th more likely explanation is no justice read the whole 2300 pages of legislative English complete with references to previous bills. I don't think they realized the problem that was being created.

I also don't think the idiots working for Harry Reid realized what they were doing in the press to get a bill to floor for the next day's vote.

Given that 30 states sued over the ACA, presumably most of those will not implement the medicaid expansion. Worse still for the progressives is now that court said the states can't be coerced in to further medicaid expansion the issue now becomes when does coercion become coercion? If the expanded medicaid program can be considered coercive then what about the threats to withhold the underlying program if a state were to opt out? Or the mandates that come with federal education funding or such mandates?

Unless the economy has a rapid and miraculous recovery Choom & Co. (assuming the worst electoral outcome) are going to have to deal with states that can no longer afford to participate in the various federal programs.

Obamacare is an utter failure, as not a single thing among the many promises has turned out to be true. Only a tiny fraction of people have actually gained coverage versus what was claimed. Costs are going up faster than before.

Frankly I'd suggest before giving out "genious points" that you consider the impact of 2,400+ pages of legislation that will result in 100,000's of pages of regulations. It would be almost impossible not to end up with mutually destructive circumstances.

As an example post-passage it was discovered that congressional employees, those working directly for members of Congress, would lose their regular healthcare and be required to get their healthcare insurance from the state Exchanges. The legislation required said Exchanges to be implemented in 2014. Which is plainly idiotic since that would require the workers to buy private health insurance for 2+ years until the Exchanges got implemented.

The first of many unintended consequences. I was thinking that like the debt clock they should have a running tally of unintended consequences. I'm not sure how one could quantify that, however. Perhaps they could have a running tally of deaths due to delayed treatment.

As to the posts on comparing the U.S. with Canada's health care system, my parents go south for the winter and the many Canadians all seem to have their hip replacements and other surgeries or medical treatments in the U.S. while they are wintering in the U.S. Coincidence?

King Obama said it was time to move on. Didn't these states get the memo? Well, these Governor's will pay a horrible price this November for opposing obamacare. Just you wait. Like the great pumpkin, that retribution is just around the corner. Yes siree

The stats, published in Investor's Business Daily, were compiled by the staff of (then U.S. Rep., now) U.S. Mark Kirk, IL. A version with sources is available on the website of Rep. Charlie Dent (R PA-15). You may not agree that these are appropriate comparisons, but it is hard to argue with the fact that we Americans don't wait for care like the British and Canadians.http://dent.house.gov/index.cfm?p=PressReleases&ContentRecord_id=a7b821dc-0079-4ffc-9a42-1371a7d52863&ContentType_id=c6ec3657-dc1e-476f-8d55-369892a8b74d&Group_id=7a83093f-b0df-4c08-affb-9f5cf4ef7c2aA link to the article may not be available, but the graphic they used was attributed to Kirk.http://tonyphyrillas.blogspot.com/2009/05/how-american-health-care-stacks-up.htmlhttp://1.bp.blogspot.com/_17eIBlDU-ps/Sh3AyiFPu5I/AAAAAAAAEuM/9q1eMHET5TM/s1600-h/lookpic052709.gif

Look the justices are clearly just trying to make the issue as interesting politically as possible. The ruling on the mandate led to far more interesting talking points on the matter than any other possible ruling, with Obama denying it is a tax when Roberts says it was. In the same way, this part of the ruling does it. The justices are hiding behind legal doctrine and arguments, in their quest to have a really interesting political scene to open the popcorn to.

Danno said...As to the posts on comparing the U.S. with Canada's health care system, my parents go south for the winter and the many Canadians all seem to have their hip replacements and other surgeries or medical treatments in the U.S. while they are wintering in the U.S. Coincidence?

By law, our ER's can't turn away needy Canadians, even though we're less hip than they are.

An unpopular 2700 page partisan bill, passed via parlimentary shenanigans and congressional paybacks/bribery, intentionally designed to vastly increase the size and scope of government, and found constitutional only after extreme legal contortions, will have unintended consequences?

I'll not opine on what Breyer or Kagan saw in the future, but by questioning why they would agree with the majority Ms Althouse you suggest that their motivation is to preserve Obamacare regardless of their reading of the law. If Roberts is to be credited with not saving the public from the consequences of their decisions, why should we not credit Breyer and Kagan with not saving the legislative branch from the consequences of bad drafting. The situations seem symmetric. And you seem to be assuming that Breyer and Kagan would rule politically rather than constitutionally if only they saw the consequences of their ruling. Hmmmm.

"For example, 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman;"

About 25 years ago, I tried to schedule a breast biopsy on a Saturday because I was leaving town Monday and didn't want the patient to wait. As it happened she was a hospital volunteer but had no insurance. The OR supervisor refused to schedule it. She said I was doing it for my own convenience. In fact, I was doing it for the patient's but to no avail.

I commented that I hoped the supervisor never had an urgent medical issue that was delayed by an uncaring staff person.

When I got back from my trip, I found the supervisor was telling everyone that I had said I hoped she got cancer. The patient got her biopsy at the county hospital and didn't volunteer anymore.

About a month later, the supervisor's husband, an electrician, came in with a severe electrical burn of his arm. She was in a big hurry to get care that time.

I didn't say anything.

I certainly wouldn't wish Obama any medical problems. Of course, he won't have to go to an exchange. One of Gingrich's Contract with America provisions was that legislation applied to Congress, too. I wonder how much of that is still in force?

I call BS on ApAp's stats as well. They appear to originate in a letter from the office of then U.S. Rep. (now Sen.) Mark Kirk (here's a link to the archived page at the WayBack Machine). Beyond the fact that Kirk is not exactly known for his honesty (you'll likely recall the I-served-in-Iraq dustup), he relies on mainly right wing think tanks, particularly the Heritage Foundation, to back up his claims. And it appears the stats have have taken on a life of their own in their passage through the conservative blogging sausage grinder, becoming just a BIIIIT more extreme, and a few completely new "facts" seemingly stitched from whole cloth.

So the optimal choice for a state to avoid expanded Medicaid liabilities down the years - but keep the federal funds flowing ti its residents and healthcare providers - would be for the state to (1) decline the Medicaid expansion and (2) create an state exchange?

The optimal way is for a state to refuse to expand these costly expansions of the welfare state so the truly shiftless will re-locate to another state that offers all the free goodies. [I am being half-serious here].

The only thing that matters is that the pre-existing conditions non-discrimitory clause remains. Republicans will never get rid of that. Hence, they will never be able to get rid of universal health care.

The stats by country should be available and retrievable or how could anyone measure which country works best? And how could libruls credibly claim we spend too much with no difference in outcomes if the data is not available?

I call bullshit on the lying libruls here who find fault with April Apple's claim. Prove she is wrong Garbage & Allie.

"The stats by country should be available and retrievable or how could anyone measure which country works best?"

If I remember right, and my memory might be faulty on this, one of the issues is that different countries use different definitions of terms and different metrics.

As an example in the USA if an infant dies for any reason, including being premature, then it is counted against infant mortality. While in European countries they count it as a failed delivery like perhaps a miscarriage. Which is one reason why infant mortality is so relatively high in the US.

btw this doesn't make the US better nor worse. It's just that without matching data definitions it is hard to compare data sets.

Wait Times. The United States is one of eight OECD countries in which waiting times for elective surgery are reported to be low. Meanwhile, wait times are considered a serious health policy issue in 12 OECD countries. In these 12 countries, wait times of 1 to 1½ months are common for procedures such as invasive heart surgery, whereas wait times for procedures like hip or knee replacement cluster around five months. In a recent survey, a quarter to a third of respondents in Canada, the United Kingdom, and Australia reported waiting more than four months for a non-emergency procedure, compared with only 5% of Americans.

Wait times are usually tied to capacity of the health care system, with low numbers of hospital beds and physicians typically associated with long wait times. Interestingly, the United States is the exception to this rule: here, low levels of beds and health care providers have not been accompanied by long wait times for elective surgery. International trends suggest that wait times are also associated with low total health spending; however, the exception to this rule is Japan, which spends only $2,249 on health per capita (compared with $6,102 in the United States) yet does not have a wait time problem. Wait times are more common in countries where physicians are paid by salary (such as in the United Kingdom) instead of on a fee-for-service basis (as in the United States).

AJL said: "The stats by country should be available and retrievable or how could anyone measure which country works best?"

No, they're not. These are one off studies (they are not repeated from year to year) the links to which are not provided, dead, or behind paywall. I wouldn't accept Heritage as a source anyway, nor would I expect you to accept an analogous left wing organization if one exists.

The funny thing about the stats mentioned, is that they are NOT outcomes in themselves, but interstitial conditions which the original writer presumptively deems desirable (e.g. treatment within 6 months, number of scanners). The REAL dependent variables should be quality of health, should it not? Who is to say that 6 months is preferable to longer waits. What if longer waits were associated with better results. Interestingly, that IS the case.

The CIA keeps year to year account of relevant data in the World Fact Book. Here are a few stats of how the 3 nations compare (numbers in parenth. are ranking among 222 countries with higher=better except for life expec.):

You know where the US ranks really well? Health expenditures -- 2nd highest at 16.2% of GDP. UK is 39th highest at 9.3% of GDP, and CA is 22nd highest at 10.9% of GDP. So basically, we're paying more for less.

But why limit ourselves to UK and CA. Why not compare the US to the REAL extremist, leftist, socialists -- the Scandinavian countries. Oh, I know. Because they kicks our ass in every measure of health outcome at a fraction of the cost!

I think that career leftists like Kagan and crew are just fine with the costs being tossed back on the feds because that centralizes even more power and is another step closer to single payer or national health care.

Since when has a leftist ever worried about cost? How naive would you have to be to think that such a thing even enters into their thinking? What is cost compared to social justice?

And given the current administration's penchant for bullying the states you KNOW they would LOVE setting up federal exchanges in each state for the graft and patronage opportunities alone. This thing was meant to blow up which is why they didn't even bother reading the fine print.

Besides, if push comes to shove they can always get a Supreme Court justice to substitute whatever words they like for the ones actually in the law so they will get as many bites at the apples as they want. All they have to do is get a couple of law professors to unfriend Roberts on Facebook and he will rule however they like for fear no one will like him anymore.

ALL of our institutions have failed. Whether this thing stands or not we have enough abominations already on the books that bankruptcy is all but inevitable and Mitt Romney is exactly the wrong alternative at the wrong time. We might as well just stand aside and let the Dems have everything they want so that we can start over from scratch all the sooner because there is no way this bitch is going to end up anywhere else than the ditch.

What if longer waits were associated with better results.[?] Interestingly, that IS the case. How could you be so ignorant and/or senseless to believe this? It completely destroys your credibility on the subject.

I've lost a brother-in-law and a former housemate in the last 2 years because they delayed seeing a doctor. If I'd delayed having a melanoma removed 20 years ago, I'd be long dead by now. Today I had a root canal because I delayed having a filling replaced because I hate dentists.

Incidently, I called the dentist as a new patient at 9 am and got an appointment for 10 am. Course, it will cost me ~$2000, thanks to you jerks with subsidized dental insurance.

"But why limit ourselves to UK and CA. Why not compare the US to the REAL extremist, leftist, socialists -- the Scandinavian countries. Oh, I know. Because they kicks our ass in every measure of health outcome at a fraction of the cost!"

Nobody talks about the reasons for this sort of thing. Scandinavian countries, until recently with Muslim immigrants, were all white and mostly middle class. The racial minorities in the US, chiefly black but also Hispanic illegals, have far worse health care outcomes than whites.

Some of the reasons are economic but some are unknown. The military did a study of birth weights among white Hispanic and black women who were active duty or dependents. All had the same prenatal care and all were of similar economic situation. Blacks had the lowest birth weights, whites next and Hispanics the highest. Black males have reduced life expectancy and higher rates of hypertension and prostate cancer.

You're trying to make a point but your facts are not that supportive of it.

There are significant differences among the Scandinavian countries. Norway, for example, has a big issue with transportation because so much of the population is isolated from cities. Hospital length of stay is longer.

" Jay Retread said...The only thing that matters is that the pre-existing conditions non-discrimitory clause remains. Republicans will never get rid of that. Hence, they will never be able to get rid of universal health care."

France has a good solution for that and it does not involve anything like Obamacare. Certain diagnoses, including most of the "pre-existing conditions" are covered 100% by something similar to our risk pools. If you have diabetes or cancer, it is covered but unrelated diagnoses must go through the plan with co-pays, etc.

That way, the catastrophic conditions are covered but everyone else does not have their health care destroyed.

Unlike rejecting federal funds for a train, rejecting this federal program will involve State politicians pointing a finger directly at a large number of people (those who will be eligible for the new program) and saying "fuck you".

"The only thing that matters is that the pre-existing conditions non-discriminatory clause remains. Republicans will never get rid of that. Hence, they will never be able to get rid of universal health care. "

I am so tired of this. You want to see the pre-existing condition problem go away. I mean, CEASE TO EXIST?

Make coverage of people with pre-existing conditions a deductible expense for the health care providers.

Considering that the private sector is always more cost-efficient than government, the feds and states save money right there. The cost of maintaining state treatment of uninsurables I suspect far outweighs the "lost revenue" of tax deductions by the healthcare providers.

This has, of course, not been seriously considered by any politician because it is an incentive-based plan and not a compulsion-based plan. Modern government knows we have to be driven to do the right thing, not rewarded for it.

"The only thing that matters is that the pre-existing conditions non-discriminatory clause remains. Republicans will never get rid of that.”

They don’t need to. Romney came out in favor of prohibiting denial for pre-existing conditions provided that the insured had maintained pre-existing coverage. I.e. if you paid your insurance premiums and kept them up and then make a claim, you can’t be denied coverage on the grounds that your ailment was pre-existing but if you didn’t have health insurance or pay the premiums, you can’t wait until you’re sick to buy it and force the company to pay for your claim.

Several of you objected to my "What if longer waits were associated with better results. Interestingly, that IS the case."

Like it or not, there is a correlation between waits and outcomes. Countries with socialized medicine have both longer waits and better outcomes. I didn't say waits CAUSED better health. I said they were associated. And I find that interesting.

jimspice, you are quite wrong. You've confused life expectancy with health care outcomes.

They are not the same. Life expectancy is dominated by lifestyle factors - obesity, traffic accidents etc. Health care outcomes, the measure of how well people do once diagnosed with a disease, are not the statistics you coughed up. Things like survival rates for cancer, heart disease survival rates and such, those are where the US has significantly better outcomes than the socialized health care systems you purport to praise.

Interesting factoid about universal health care. "The Nobel Prize for medicine tells the rest of the story. During the last century, the United States’ free market medical care system was rewarded with 72 Nobel prizes. The Soviet Union, which invented the nationalized health care system, won none. Zero. (Tsarist Russia did get one Nobel Prize for medicine in 1904, for Pavlov’s conditional reflex theory.)"from http://pjmedia.com/mihaipacepa/2012/07/06/romanias-20-year-nightmare-unraveling-socialized-health-care/2/ for those that want links.

As I posted somewhere else, the only innovations I've seen to come out of national health care are volutary followed soon thereafer by involuntary euthanasia.

@Robin: Jimspice seems like the kind of fellow who wouldn't mind seeing the US combat obesity with a little Soviet-style starvation. He probably thinks it would be "good for us" just like it would be "good for us" to have $6/gal gasoline.

The motivational aspect is the hardest part for such lefties to argue. Lack of innovation always does in social control experiments.

One other item that needs to be added because it is true, is that America has two separate health statistics for virtually every health outcome. In fact, for virtually everything that can be measured in a society.

Black statistics and non-black statistics.

The non-black statisitcs put the United States at the top of the world in almost every positive outcome for health. The Black statistics drag the numbers down to a frightening degree. And moreso if looked at by themselves. The chances of dying a violent death as a Black? (more then likely at the hands of a Black) More then a order of magnitude higher then the chances of dying a violent death for a non-Black. Infant mortaliity statistics, using U.S. figures- any child born alive who dies is a death (overseas if an infant dies before 24 hours, it is not cvonsidered a live birth...)? Far worse for Blacks then non-Blacks. And so on and so forth.

And as far as health statistics go, ones from the U.S. are probably the only ones that be trusted to give any real meaning.

And the same with longevity. A few years back a Japanese prefecture decided to host a birthday celebration for one it's 99 year old residents going on a century. They couldn't find him. Turns out that on further examination, he had been dead for a few years. All of his pension checks had been cashed and spent, but he was dead. They started searching for some other older pensioners, and couldn't find a significant percentage of them. I don't think their longevity statistics have been updated to refelect this...